(AFO)-Ankle Foot Orthotics Letter of Medical Necessity
Patient Name:
Date:_____________
DIAGNOSIS:
o
o
o
Low back pain
Lumbar disc degen
Walking difficulty
724.2
722.52
719.7
o Lumbar disc syndrome 722.10
o Lack of Coordination 781.3
TREATMENT PLAN
INDICATIONS (check those appropriate)
o
o
o
o
o
Symptomatic relief and management of chronic intractable pain
Prevention of retardation of disuse atrophy by causing the patient to ambulate
Increasing local blood circulation
Relaxation of muscle spasm and pain
Muscle re-education
DURATION OF NEED
o
o
o
12-MONTHS
LIFE
USE INDEFINITLY PRN PAIN
PROGNOSIS
o
o
o
FAIR
GOOD
EXCELLENT
EXPECTED BENEFITS FROM AFO (check appropriate box/boxes)
o
o
o
Significantly increase mobility
Significantly increase balance
Improved clinical picture
Instructions for Use:
Frequency of use (_____ times per day )
Length of use (_____ days, weeks, months)
Time of treatment (30 mins, other ________)
Utilizing accepted medical practice standards the above-prescribed durable medical equipment (AFO) is essential in the
continuous treatment of this patient. This AFO helps to alleviate pain and increase rehabilitation by aiding and
improving ambulation, which will improve lower extremity stability.
_______________________________
(Insert Clinic Name)
Insert clinic address
Insert city, state, and zip code
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Proof of delivery form for AFO
Patient Name_______________________________________
I have received an Ankle Foot Orthotics from Dr. .
I am satisfied with both the workmanship fit of the AFO at the time of delivery. I have
also been advised as to the use and understand its limitations. I also understand a
guarantee on its components, under normal use is extended for 90 days after delivery
which time the company will make any repairs necessary to maintain the appliance in
good working condition.
I have read the compliance Resolution policy and have been provided with a copy of the
abbreviated 21 Medicare Supplier Standards.
_____________________________
Patient Signature
Date
Staff
Date
Signature
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All rights reserved